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Eisenman DP, Gelberg L, Liu H, Shapiro MF. Mental Health and Health-Related Quality of Life Among Adult Latino Primary Care Patients Living in the United States With Previous Exposure to Political Violence. JAMA. 2003;290(5):627–634. doi:10.1001/jama.290.5.627

Context Although political violence continues in parts of Central America, South
America, and Mexico, little is known about its relationship to the health
of Latino immigrants living in the United States.

Objective To determine (1) rates of exposure to political violence among Latino
adult primary care patients who have immigrated to the United States from
Central America, South America, and Mexico and its impact on mental health
and health-related quality of life and (2) frequency of disclosure of political
violence to primary care clinicians.

Design, Setting, and Participants Two-stage cluster design survey of a systematic sample of Latino immigrant
adults in 3 community-based primary care clinics in Los Angeles, conducted
from July 2001 to February 2002.

Main Outcome Measures Reports of exposure to political violence in home country before immigrating
to the United States and communication with clinicians about political violence;
self-reported measures of health-related quality of life using the Medical
Outcomes Study Short Form 36 (MOS SF-36); symptoms of depression, anxiety,
and alcohol disorders using the Primary Care Evaluation of Mental Disorders
(PRIME-MD); and symptoms of posttraumatic stress disorder (PTSD) using the
PTSD Checklist–Civilian Version (PCL-C).

Results A total of 638 (69%) of 919 eligible patients participated. The nonresponse
rates did not differ by age, sex, recruitment sites, or clinic sessions. In
weighted analyses, 54% of participants reported political violence experiences
in their home countries, including 8% who reported torture. Of those exposed
to political violence, 36% had symptoms of depression and 18% had symptoms
of PTSD vs 20% and 8%, respectively, among those not exposed to political
violence. Controlling for age, sex, country, years lived in the United States,
acculturation, income, health insurance status, and recruitment site in a
subsample of 512 participants (56%), those who reported political violence
exposure were more likely to meet symptom criteria for PTSD (adjusted odds
ratio [AOR], 3.4; 95% confidence interval [CI], 1.4-8.4) and to have symptoms
of depression (AOR, 2.8; 95% CI, 1.4-5.4) and symptoms of panic disorder (AOR,
4.8; 95% CI, 1.6-14.4) than participants not reporting political violence.
Those exposed to political violence reported more chronic pain and role limitations
due to physical problems, as well as worse physical functioning and lower
perceptions of general health than those who were not exposed to political
violence. Only 3% of the 267 patients who had experienced political violence
reported ever telling a clinician about it after immigrating; none reported
their current physician asking about political violence.

Conclusion Latino immigrants in primary care in Los Angeles have a high prevalence
of exposure to political violence before immigrating to the United States
and associated impairments in mental health and health-related quality of
life.

Political violence is increasingly recognized as a threat to public
health and includes many types of violence such as war, torture, forced disappearances,
and extrajudicial killings.1- 3 Much
research on the long-term health consequences of political violence has focused
on torture and not on the wider problem of political violence experienced
by immigrants and refugees.4- 8 This
is especially pertinent to immigrants from Mexico, Central America, and South
America, who experienced war-related violence and political violence (including
forced disappearance of family members and witnessing a massacre9)
during the wars, military repressions, guerrilla insurgencies, and human rights
abuses of the 1970s to the present.

Prior studies examining the impact of torture and related violence have
limited relevance to US-based populations of immigrants and refugees and to
primary care clinicians practicing in the United States. These studies focused
mainly on posttraumatic stress disorder (PTSD) and depression10- 13;
were performed among asylum seekers,14 refugees
living in refugee camps in the developing world,8,15 or
persons in specialty clinic settings10,16,17;
and limited covariates to demographic variables.12,18

In this study of exposure to political violence among Latino immigrant
adult primary care patients, we assessed the following: (1) the prevalence
and types of political violence they had experienced before immigration, (2)
whether prior exposure to political violence was a key predictor of their
current mental health status and health-related quality of life, and (3) the
rates of disclosure of political violence to primary care clinicians.

Methods

Study Population and Subject Recruitment

We surveyed adult patients in 3 community-based, primary care clinics
in Los Angeles, using a 2-stage, clustered design. The sampling frame included
the 28 clinics operating under a private-public partnership plan in 2 service
planning areas (4 and 6) of Los Angeles County, located in the central and
southern regions of the county. Exclusion criteria for clinic participation
included providing only pediatric care and being housed in a drug or alcohol
detoxification center. Also, practical fieldwork considerations led us to
exclude sites that served fewer than 25 adult patients per session (a session
was defined as a discrete, continuous, 4- to 5-hour period of time spent seeing
patients in the clinic and occurring in the morning, afternoon, or evening),
provided less than 10 sessions per week, and were not within geographic boundaries
formed by specific freeways (to reduce travel time). After applying the exclusion
criteria, there were 10 eligible sites. We canvassed these 10 sites and used
available data on Los Angeles County clinic utilization to identify sites
where 50% or more of the patients were immigrants from Central America, South
America, or Mexico. This excluded 7 sites. The 3 eligible sites participated
in the study. The 3 sites, which included general internal medicine and family
medicine practices, serve approximately 24 000 adult patients per year
and are demographically similar: they are freestanding clinics offering adult
medical, pediatric, and obstetric-gynecologic services to a mainly uninsured
Latino population. None of the sites had special programs targeted to particular
populations such as new immigrants, refugees, or migrant workers.

Within each site, we selected a systematic sample of patients in which
every nth patient was recruited to participate in
the study. We devised an algorithm for this sampling fraction that maximized
our ability to recruit our required sample size during the study period, July
2001 to February 2002, by sampling about 10 persons per clinic session. The
formula for the sampling fraction, 1/n, was determined by calculating 1/n
= (No. of scheduled clinic appointments in the clinic session) divided by
10; n ranged from 2 to 8 as patient volume changed and averaged 4. We recruited
during all clinic sessions including evenings and weekends.

Bilingual/bicultural interviewers observed patients as they registered
at the front desk for their physician visit and selected every nth patient to approach for the study. The interviewer told the patient,
"We are doing a study of adults who were born in Central America, South America,
or Mexico" and determined eligibility using a face-to-face screener assessing
age and country of birth. To reduce screening and enrolling participants at
multiple appointments, the screener asked whether the patient had "done this
interview before." Patients were eligible if they were 18 years of age or
older, born in Latin America, denied being screened in the past, and able
to give informed consent in Spanish or English. Eligible patients were invited
to learn more about the study in a private room. The interviewer explained
that the purpose of the study was to examine "stressful or traumatic experiences
and how they influence health" and that responses were confidential. Participants
who signed or marked an informed consent form were interviewed in Spanish
or English while they awaited their appointment. At the end of the interview,
participants were reimbursed $10 and received a brochure with contact information
for a local refugee trauma program. Interviewers received 5 days of training
in trauma, relevant political history, interviewing methods, and practice
interviews with Latino primary care patients. Inter-rater reliability was
assessed until 100% concordance was achieved among the interviewers in use
of the measures of political violence. The UCLA Human Subjects Protection
Committee approved the study.

To obtain sufficient power to detect differences in outcomes between
the groups that did and did not report political violence, we estimated that
438 participants (219 in each arm) were required to detect a relative risk
of 1.5 for PTSD where the prevalence of the outcome in the comparison group
is 10% (type I error = .05; type II error = .10).5,8,19 Assuming
a prevalence of 33% of political violence experiences (from pilot data), this
required approximately 663 enrollees. We used 90% power in the calculation
to accommodate the underlying design effect from the 2-stage cluster sampling
design so that the 438 patients would provide sufficient power to detect the
differences of interests between the 2 arms.

The interview began with sociodemographic items and an inventory of
political violence events. Endorsement of any political violence item allowed
the participant to continue the interview. Based on the expectation that 67%
would not report political violence exposure, initially a random subsample
of participants who did not have a positive response on the inventory was
selected for further interviewing to achieve equal numbers with and without
the exposure. When preliminary analysis found an exposure prevalence closer
to 50%, all participants completed the interview regardless of exposure status.
As a result, we present the prevalence estimates of exposure to political
violence on the sample of 638 participants and the health outcomes comparisons
on the subsample of 512 participants. There were no differences in mean age,
sex distribution, country of origin, recruitment sites, or clinic sessions
between the excluded and included participants without exposure to political
violence. To further minimize the possibility of multiplicity during data
analysis, we created a unique code for each participant using the first 3
letters of the mother's maiden name and the patient's birth date and we determined
that there were no repeat participants.

Of the 1360 patients systematically identified at registration, interviewers
approached 1287; 73 (5.4%) patients who began their office visit before the
interviewers could recruit them were not approached. Of the 1287 approached,
368 (28.6%) were ineligible. Of the remaining 919, 281 (30.6%) refused participation.
Overall, 638 (69%) of the eligible patients approached agreed to participate.
The nonresponse rates did not differ significantly by median age range and
sex (interviewer observed), recruitment sites, or between weekday, evening,
and weekend clinic sessions. All 638 patients participated in the survey of
political violence exposures. Five hundred twelve (56%) of the eligible patients
were selected for the main analyses of mental health and health-related quality
of life outcome.

Measures

The complete 154-item interview was designed to last 45 minutes. The
decision to use a structured interview to assess political violence required
the development of a new 9-item instrument because no such instrument existed
for Latino (mainly Central American and Mexican) populations. An event-specific
checklist was developed, rather than allowing political violence to be self-defined
by the participant through administration of general open-ended items, to
improve comparability and quantification of the effects of specific events,
and to avoid the difficulties presented by the possibly varying meanings of
political violence among cultures.20 The frame
for items in the trauma inventory was adapted from the Exposure to Community
Violence scale,21 which has been used with
Latino adolescents and required minimal adaptation for our population. Participants
were read the following statement: "I'm going to read descriptions of various
kinds of violence and things related to violence done by the police, army,
or other political groups that you may have directly experienced or witnessed
in [your country]. Do not give answers for things you have seen on television,
radio, the news, or in the movies. Rely on real-life experiences only, as
best as you can remember. For each description, let me know ‘yes' if
the event did happen to you or ‘no' if the event did not happen to you."
The trauma inventory incorporated 7 of the 8 generic dimensions of trauma
as set out by Green (threat to life/limb; severe physical harm/injury; receipt
of intentional harm/injury; exposure to the grotesque; violent/sudden loss
of a loved one; witnessing/learning of violence to a loved one; causing death/severe
harm to another).22 We developed each of the
7 subcategories with events specific to Latino political violence experiences
chosen from the available literature (M. Hollifield, MD, unpublished data,
2000),23,24 experiences of Latino
clients attending a local refugee trauma program, and interviews with knowledgeable
representatives of the target population, including a Salvadoran military
officer.

The instrument was prepared in English and translated into Spanish incorporating
back-translation. It was cognitively tested and pilot tested in both languages
with 3 Latino primary care patients and 3 Latino clients of the local refugee
trauma program. Cognitive testing involved probing interviews with participants
who were not included in the study to assess their understanding of the questions
and their thinking as they provide the answer, to identify covert problems
not otherwise apparent in the design and review process. Based on the cognitive
and pilot interviews, the instrument was modified to improve linguistic acceptability
and clarity.

After administering the checklist of political violence events, the
interviewers administered the other measures, which included the following:
health-related quality of life was measured using the Medical Outcomes Study,
Short Form 36 (SF-36) physical health subscales and summary scores25; the Primary Care Evaluation of Mental Disorders
(PRIME-MD) Patient Health Questionnaire evaluated symptoms of mood, anxiety,
and alcohol disorders; and the PTSD Checklist–Civilian Version (PCL-C)
assessed Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV) symptoms of PTSD.26 Disclosure
of political violence to primary care clinicians was assessed using items
from a study by Rodriguez et al.27 In this
study, communication with clinicians about intimate partner abuse was assessed
by asking participants if they had "ever mentioned or discussed abuse with
a doctor," in response to direct clinician questioning or in the absence of
direct clinician questioning. These items were already translated into Spanish
and were modified to fit political violence. The interview also contained
questions about socioeconomic, service utilization, and immigration-related
characteristics.

Definition of Political Violence

Participants were considered exposed to political violence if they answered
"yes" to ever directly experiencing one of the political violence events at
any time in their life while living in their country of origin. Participants
were defined as not being exposed to political violence if they answered "no"
to all the defining questions. This operational definition is similar to that
used in prior and ongoing studies.24

Statistical Analysis and Multivariate Modeling

We constructed an analytical weight for each respondent. All analyses
incorporated these weights. The analytical weight combined a sampling weight
adjusting for the differential selection probabilities across clinic sessions
and a multiplicity weight adjusting for visit frequency, since patients with
more visits had a greater chance to enter the sample than those with fewer
visits during the study period. Persons who screened negative for exposure
to political violence had a different probability of being selected for the
interview in the period in which every other person with a negative screen
was included and the period in which all persons with negative screens were
included. We therefore incorporated a third weight component in the analytical
weights for all persons who screened negative for exposure to political violence
to adjust for the differential probability of inclusion in the sample between
the periods. Applying this final weight component permits adjustments that
reduce biases in the calculations. Analyses were implemented with STATA 7.0
statistical software (STATA Corp, College Station, Tex). P≤.05 was considered significant.

Point estimates and 95% confidence intervals (CIs) for rates of political
violence were estimated overall as well as stratified by county of origin.
Participants were classified as with and without a positive response to the
violence items, and bivariate analyses were conducted between the binary response
and the covariates, the clinical outcomes, and the quality of life measures.
In the description of the sample, we report P values
estimated from logistic models fitted through STATA survey estimation procedures,
which take into account the design effect of the cluster sampling. Two group t tests were used for comparison of continuous measures.
We used logistic models in the bivariate analysis of the association between
political violence and mental health outcomes also with survey estimation
procedures. The corresponding odds ratios (ORs) and their 95% CIs were calculated
to assess the magnitude and significance of these bivariate associations.
We used analysis of variance (ANOVA) models to compare the mean health-related
quality of life scores across the political violence exposure groups and report
the corresponding F tests for comparison of the mean scores.

We adjusted the analyses for covariates including age, sex, country
of origin, years of education, marital status, income, years lived in the
United States, level of acculturation, insurance status, and site of recruitment.
We selected these variables because either they were associated with violence
and health status or because previous studies and a priori theoretical judgment
indicated they should be included in the models. Statistically, confounding
was determined by correlations between the independent variables of r greater than 0.4 or between the independent and dependent
variables of r greater than 0.1. We used separate
multivariate logistic regression models to assess the association of political
violence with each mental health outcome variable controlling for these covariates.
Odds ratios and 95% CIs were computed for each variable and are presented
only for the political violence variable. We used separate analysis of covariance
(ANCOVA) models for each subscale of the MOS SF-36 and the summary scale to
assess the mean health-related quality of life scores within the political
violence exposure groups adjusted for these covariates. We computed 2 sample t tests assuming unequal variances for comparison of the
mean scores. Effect sizes for the difference in MOS SF-36 subscale scores
and summary scores were calculated by dividing the difference between the
mean scores in the 2 groups by the SD of the comparison group.28

Results

As shown in Table 1, the
638 participants in the overall sample had a mean age of 46.1 years (47.5
years among those exposed to political violence, 45.1 years among those not
exposed; P = .02). Twenty-five percent were male
(25.6% of those exposed to violence, 24.9% of those not exposed; P = .90). Two hundred sixty-five (41.5%) immigrated from Mexico (14.6%
of those exposed to violence, 62.8% of the nonexposed; P<.001), 207 (32.5%) from El Salvador (54.8% of those exposed to
violence, 14.9% of the nonexposed; P<.001), 113
(17.7%) from Guatemala (22.4% of the exposed, 14.0% of the nonexposed; P = .09), and 53 (8.3%) from other Latin American countries
such as Honduras, Nicaragua, Cuba, and South America (8.2% of the exposed,
8.4% of the nonexposed; P = .70).

Of the total sample of respondents, 512 answered both the trauma and
health surveys. The characteristics of the 638 participants and the subsample
of 512 did not differ significantly by mean age, sex distribution, and country
of origin (Table 1).

Of the 512 participants in the subsample, 54.9% (281) reported experiencing
political violence in their country of origin, and 45.1% (231) reported no
exposure to political violence in their country of origin. Characteristics
of study participants according to exposure to political violence are presented
in Table 2. Those who reported
exposure to political violence more often had a deceased spouse (10.9% vs
4.3%, P = .01), were older (mean age, 47.5 years
vs 44.4 years; P = .006), had lived in the United
States fewer years (mean, 14.4 years vs 16.8 years; P =
.003), had more education (mean, 8.2 vs 7.3 years; P =
.04), and were more often male (25.6% vs 18.2%; P =
.04) than those who reported no exposure to political violence. There were
no differences in the median annual income range ($10 000-$15 000)
and proportions with medical insurance (6% vs 18.6%, P =
.15) between those exposed to political violence and those not exposed.

Patients reporting political violence had greater mental health problems
compared with patients not reporting political violence. Mean (SE) symptoms
scores for PTSD were higher (37 [0.9] vs 30 [0.8]; P<.001)
as were mean depression scores (9 [0.4] vs 6 [0.4]; P<.001)
among persons reporting political violence. Of those exposed to political
violence, 36% had symptoms of depression and 18% had symptoms of PTSD vs 20%
and 8%, respectively, among those not exposed to political violence. Overall,
in bivariate analyses, those exposed to political violence were more likely
than those not exposed to symptom criteria for PTSD, depression, and any mental
health disorder (Table 3). In
separate multivariate logistic regressions controlling for age, sex, country
of origin, education, marital status, income, years lived in the United States,
level of acculturation, health insurance status, and site of recruitment,
exposure to political violence was associated with a greater likelihood of
having symptoms of PTSD, depression, and any mental health disorder. Similarly,
adjusting the mean (SE) symptom scores for the same covariates did not change
the association between political violence and PTSD (36 [0.8] vs 27 [1.2], P<.001) or political violence and depression (7.7 [0.4]
vs 5 [0.5], P<.001).

Patients reporting political violence compared with those not reporting
political violence had significantly worse health-related quality of life
scores in the MOS SF-36 domains (in which lower scores indicate poorer health)
of physical functioning, role limitations due to physical health problems,
chronic pain, general health perceptions, and the physical health summary
scale (Table 4). In multivariate
ANCOVA models controlling for age, sex, country of origin, education, marital
status, income, years lived in the United States, level of acculturation,
health insurance status, and recruitment site, political violence continued
to be associated with poorer health scores in all domains. The effect size
for political violence on role limitations due to physical problems was 0.36
SD and 0.30 SD for political violence on chronic pain.

Among the 267 participants who reported experiencing political violence
in their country of origin and 1 or more prior visits to a health care professional
during the past year, only 7 (3%) ever told a physician about it. None reported
that their current physician had ever asked them about political violence.

Comment

Our study found high rates of exposure to political violence in the
country of origin among adult Latinos who immigrated to the United States
from Central America, South America, and Mexico and who attended primary care
clinics that primarily serve Latino patients. More than half (54%) of the
study participants reported experiencing political violence in their home
country.

In our study, 8% of participants reported exposure to torture in their
country of origin, which is consistent with findings from a previous study.29 In another study of posttraumatic stress symptoms
among a Central American community sample in Los Angeles, 37% reported that
they had fled their country as a result of war.12 However,
in a study of Central American immigrants attending a primary care clinic
in southern California, only 18% reported "war-related violence" experiences.30 These differences may be due to several factors,
including our use of an event-specific checklist rather than allowing "war-related
violence" to be self-defined by the participant through administration of
general open-ended items and our use of the broader concept of political violence
instead of war-related violence.

Political violence exposure was associated with symptoms of depression
(36% of those exposed to political violence), panic disorder (11%), and PTSD
(18%), even after controlling for patient characteristics and recruitment
site. Political violence exposure was also associated with reports of greater
chronic pain, impaired physical functioning, and low scores of health-related
quality of life. In addition, the impairment of health-related quality of
life was more severe than we anticipated. The magnitude of the effect seen
in the health-related quality of life scores (up to 0.36 SD in scores) is
comparable to or greater than differences seen comparing groups with or without
such chronic diseases as mild asthma28 and
before and after treatment for duodenal ulcer.31 However,
few of those exposed to political violence (3%) had reported their experiences
to a clinician after immigration to the United States. Our mental health and
health-related quality of life findings support the results of previous studies
that found higher unadjusted scores for symptoms of depression, PTSD, and
anxiety associated with political violence exposure in Latino immigrants.11 While the rate of symptoms of depression in the nonexposed
group (20%) was comparable to published ranges in Latino primary care patients,32,33 baseline rates of symptoms of PTSD
and panic disorder in Latino primary care populations are not available for
comparison. Although only about 5% of our study sample (3% of the women and
10% of the men) had symptoms consistent with a diagnosis of alcohol abuse,
these results are consistent with results from a large primary care–based
study (the PRIME-MD 1000 Study) that used the same alcohol abuse screener
and also reported a 5% prevalence of alcohol disorder in the overall sample,34 a 2% prevalence of alcohol disorder among the women,
and a 10% prevalence of alcohol disorder among the men.35

We observe that the ORs for the mental health outcomes increased after
adjustment. This is because we adjusted for confounding variables in these
models, and several of these confounding variables (origin, years lived in
the United States, marital status, and education) were significantly associated
with political violence. These confounding variables influenced the ORs through
their underlying interactions with political violence in the models and resulted
in enlarged effects of political violence on the mental health outcomes. Confounding
was determined if correlations between the independent variables were r greater than 0.4 or between the independent and dependent
variables were r greater than 0.1. Several variables
in our models were correlated: not surprisingly, education was positively
correlated with acculturation (r = 0.42) and country
of origin was correlated with political violence (r =
0.39). We chose to keep both variables in the model nonetheless.

Limitations

Certain limitations to this study should be recognized. First, the study
sample was not population based, but was drawn from a group with a higher
risk of having health problems (ie, adults receiving primary medical care
at 3 clinics that serve Latino immigrants and refugees in Los Angeles). Criteria
for inclusion of study sites narrowed the pool of potential sites from 28
to 3 and leave open the question of whether the rates for exposure to political
violence reported herein apply to the other clinics that might not focus on
serving Latino patients. Generalizing the findings to other cities or to community-based
samples is uncertain, and the question requires investigation at these levels.
Second, the measure of political violence exposure was constructed for this
study and its psychometric properties are unknown. Face validity was strong
as evaluated by refugee trauma experts, a member of the Salvadoran military,
and persons who experienced political violence as representing domains of
political violence. Third, this study is susceptible to classification biases.
The political violence measure only asked about acts of violence committed
by police, army, and other political groups. Participants who experienced
the same events that were not politically motivated were placed in the comparison
group. It is possible that the affiliation of the perpetrator was not obvious
to the respondent in some circumstances and that violent events may have been
misclassified as political violence or not political violence–related.
The direction of any bias resulting from a resulting classification error
is unknown. Fourth, although our study had a 69% response rate (consistent
with previous studies of violence exposure36- 39),
ethical considerations prevented us from collecting person-level data on nonrespondents,
so unrecognized selection bias may have occurred. Nonresponse rates did not
differ significantly by observed age range and sex or among the recruitment
sites or clinic sessions. Last, the increase in the adjusted OR for mental
health outcomes indicates the complex relationship between political violence
and health outcomes. We did not assess for any potential underlying interactions
among the confounders and political violence. Multiple independent variables
can create multiple interactions and multilevel interactions that should be
examined in future analyses.

Conclusions

The Latino population, which is the fastest growing US minority group,
comprises 12.5% of the US population.40 More
than 4.2 million Latino persons live in Los Angeles County alone, representing
44.6% of its population.40 Latino immigrants
who have experienced political violence in their country of origin who attend
primary care clinics after immigrating to the United States are an important
population to understand because they are help-seeking but are also faced
with the consequences of political violence. Central Americans and Mexicans
from certain states (Oaxaca, Guarraro, Chiapa) represent a high-risk group
for history of political violence.4,9 Political
violence has declined in Latin America in the last 10 years with the return
to democracy in most of the countries, but it has not disappeared. For instance,
torture is reported to be widespread in Mexico41,42 and
extrajudicial executions, torture, and forced disappearances are reported
to continue in Central America.43

Latino immigrants may be more likely to use primary care medical services
than specialty mental health services,44 so
the primary care clinic may provide the optimal setting for detecting exposure
to traumas and addressing the potential effects of such an exposure in the
context of an ongoing relationship with a health care professional. Those
who have experienced political violence may access the health care system
through primary care clinics, may not identify mental health problems, and
in the absence of a clinician who inquires about their history, secure less
than optimal care, including medical, mental health, and social service referrals
that address the sequelae of their political violence experiences. Clinicians
should inquire about a history of war and political violence experiences in
immigrant and refugee patients whenever the differential diagnosis includes
trauma-related illnesses, such as depression, PTSD, and chronic pain. Future
studies should assess the impact of improving clinician detection of political
violence and torture experiences on mental and general health outcomes in
this population.